Healthcare Provider Details

I. General information

NPI: 1588818975
Provider Name (Legal Business Name): DCCT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 S BIG BEND BLVD
SAINT LOUIS MO
63117-2203
US

IV. Provider business mailing address

PO BOX 9169
SAINT LOUIS MO
63117-0169
US

V. Phone/Fax

Practice location:
  • Phone: 314-610-8169
  • Fax:
Mailing address:
  • Phone: 314-610-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number101819
License Number StateMO

VIII. Authorized Official

Name: DR. REZA ROFOUGARAN
Title or Position: CEO
Credential: MD
Phone: 314-610-8169